Family Instructs Medical Negligence Lawyers To Help Establish Answers Following Dad-Of-One’s Death

The devastated widow of a man whose body was found after he went missing from a mental health unit has spoken out on losing her partner of 30 years following an inquest into his death.

Dad-of-one Adrian Horsley from Holmfirth was admitted to the Priestly Unit at Dewsbury and District Hospital following a deterioration of his mental health.

Around 11 weeks after his admission Adrian went missing from the unit, which is run by the South West Yorkshire Partnership NHS Foundation Trust, after being permitted to leave the ward on his own. He was sadly found dead later that day at Dewsbury train station on 22 March 2019, aged 48

An inquest into his death was held at Bradford Coroner’s Court this week, with Adrian’s family supported by specialist medical negligence lawyers from Irwin Mitchell.

The inquest concluded that a number of failures in the care provided by the Trust, which came to light during the course of the inquest, probably caused or contributed to Adrian’s death.

Staff were unaware of the plan of care regarding leave due to a number of issues.  Had they been aware, leave would not have been permitted.  The issues included failures of the electronic patient information system which meant that staff were unable to access Adrian’s records, the absence of a written handover sheet, limited information being provided on shift handover and staff relying on information which was 48 hours old.

Expert Opinion

"Losing Adrian so tragically has left his loved ones struggling to come to terms with what happened. The past three years have been incredibly difficult for his family, in particular Jemma who has many questions regarding his death.

While nothing will make up for her loss, we’re pleased to have been able to help provide her with the answers she deserves.

People with mental health issues are some of the most vulnerable in society. Sadly the inquest heard worrying evidence surrounding the events that unfolded in the lead up to Adrian’s death. It’s now vital that lessons are learned to help improve patient safety so that others don’t have to go through what Adrian’s family have.

We’ll continue to support Jemma as she attempts to come to terms with her loss.”

Rebecca Jones - Associate Solicitor

Adrian, who worked as a lightning protection engineer, had previously suffered from depression and was diagnosed with bowel cancer in November 2017.  He underwent chemotherapy and surgery, and had a temporary stoma fitted.

The inquest heard that he struggled with his diagnosis and suffered anxiety regarding his stoma bag.  By December 2018 his mental health had deteriorated further and Jemma said he expressed suicidal feelings.

During the early hours of 3 January, 2019, Adrian was admitted to the Priestly Unit.

On 19 March, following further suicidal comments from Adrian, the hospital agreed that he should not be allowed to leave the leave the ward unless accompanied by a member of staff, for his own safety.

Three days later, Jemma said a consultant phoned and informed her that Adrian was missing from the Priestly Unit.  He was found dead later that day at Dewsbury train station, the inquest was told. The decision to allow Adrian to leave the unit was against his doctors advice and his doctor told the inquest that, as far as he was concerned, any change to this decision should have gone through him.

Prior to his death, Adrian had been married to Jemma for 24 years.  They have one daughter, Emily, 21.

Jemma, 50, said: “It’s been more than three years since we lost Adrian and he is still very much missed by all of his family. He has left a huge hole in our lives.”

“Adrian was a wonderful husband and father but had started to struggle following his cancer diagnosis. When he went into hospital we really thought Adrian was in the best place possible to receive the support he needed.”

“While the inquest was difficult having to relive everything, we’re grateful that it’s over and we at least have some answers.  Sadly nothing will turn back the clock, so all we can hope for now is that something is learned from our tragedy so that others don’t have to suffer like us.”

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